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Your Name:
Street Address:
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Health Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

UNDERWRITING INFORMATION
 
Insured Name: Birthdate:
Insured Height: Insured Weight:
Spouse's Name: Spouse's Birthdate:
Spouse's Height: Spouse's Weight: (M/F):
 
Include Spouse?: Yes No Include    
Children?:		 Yes No
 
List children's names,
(first & last), their
relationship to you,
and birthdates:
(up to 6 children)		 Name/Rel.:B-Date:
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Does any family member living in the household use or has used any tobacco products? (if yes give dates, and details in remarks section).
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Describe usage (cigar,
cigarettes, etc, and how long.)      

 
Any Pre-existing Health Conditions?
 (If yes, descibe in detail, and to which of the insured persons they apply.)
 
Any Covered Persons Currently Taking Medication of Any Kind?
 (If yes, descibe in detail, and to which of the insured persons they apply.)

COVERAGE INFORMATION
 
How Long Do You Need Coverage For?
(if short term, etc.)
 
What Deductible Do You Want?
($250, $500, $1000, etc.):
 
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(Maternity, H.M.O., P.P.O., etc.)
 
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